Healthcare Provider Details

I. General information

NPI: 1528971488
Provider Name (Legal Business Name): KEVIN POTTER LASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 E BASELINE RD STE 208
TEMPE AZ
85283-1453
US

IV. Provider business mailing address

6504 S FOREST CT
GILBERT AZ
85298-4890
US

V. Phone/Fax

Practice location:
  • Phone: 480-209-1977
  • Fax:
Mailing address:
  • Phone: 646-805-8168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAAC-15572
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: